*Required
*First Name: First Name is required.
*Last Name: Last Name is required.
Company
(If applicable):
*Address: Address is required.
Address 2:
*City: City is required.
*State: Please select State.
*Zip: 5- digit Zip code is required.5-digit format is required.
*Phone: Phone Number is required.Invalid format 555-555-5555.(555-555-5555)
Phone Other:
Fax:
*Email Address: Email Address is required.Invalid Email address format.
*Password: Password is required.Minimum 6 characters required.Maximum 10 characters. (6 - 10 characters)
Website: (www.yourwebsite.com)
How did you hear about Illinois Medispa Association?
 
*Profession:
 
Please make a selection.

*Membership Agreement:
  Member Agreement is required.
I agree to abide by the Code of Ethics and Bylaws of the Association, to pay the annual membership as determined from time to time by the board of directors, and to exercise my rights as an active member of Illinois Medspa Association.

I certify that the information furnished by me is true and correct, and I agree that failure to provide accurate information as requested or any misrepresentation of fact(s) shall be grounds for revocation of my membership.

*Membership Type:
 
Please select Membership type.